GYNAECOLOGY GP

*FIBROIDS* / *LEIOMYOMAS* - benign smooth muscle tumour of the uterus (most common gynaecological tumour) - have oestrogen receptors so grow in high exposure - SUBSEROUS fibroids (most common) associated with calcification which can be seen on x-ray - INTRAMURAL (2nd most common): usually asymptomatic - SUBMUCOSAL fibroids (3rd most common) are more likely to symptomatic - often shrink after menopause

*AGE*: typically premenopausal >35yrs - 70% of women by age 45 will present with fibroids. *RISK FACTORS*: increasing age, obesity, nulliparity, family history, early puberty (long exposure to oestrogen), African-American *SYMPTOMS*: usually asymptomatic otherwise - menorrhagia (heavy bleed >7 days) - dysmennorhoea (painful cramps) - irregular periods - abnormal uterine bleeding +/- dyspareunia - frequency/urgency: if compressing on bladder - can cause spontaneous abortions Physical: diffusely enlarged uterus *INVESTIGATE*: - bimanual exam: irregular shaped uterus - pelvic U/S: hypo-echoic mass on endometrial wall. - hysteroscopy + biopsy for confirmation *MANAGEMENT*: only if symptomatic 1) watchful waiting: best management if patient is asymptomatic. Furthermore; they tend to regress after menopause due to lower oestrogen levels. 2) control pain and bleeding symptoms with - *NSAIDs, transexamic acid* - *OCP/Depo-Provera®* 3) to shrink fibroids: - *GnRH agonist* e.g. leuprolide which decreases oestrogen production - *ulipristal acetate* - *uterine artery embolisation* (helps shrink fibroids and improve bleeding) 4) surgery - *myomectomy* (ideal choice for those who would like to preserve fertility), - *hysterectomy* if beyond age and do not want children.

*PAP SMEAR BETHESDA GRADING* Canada guidelines - routine screening every 3 years for women between 30-69 years old in the UK - pap smear screening for all women and people with a cervix aged 25 to 64 - atypical squamous cells - low grade squamous intraepithelial lesion (CIN1) - high grade squamous intraepithelial lesion (CINII/III) - squamous cell ca - atypical glandular cells - adenocarcinoma in situ

*ATYPICAL SQUAMOUS CELLS* - atypical SQUAMOUS cells of *undetermined significance* (ASC-US): 🌀 if <30yrs: repeat cytology @ 6 months 🌀 if >30yrs: HPV testing and if positive; refer for colposcopy - atypical SQUAMOUS cells *cannot exclude HSIL* (ASC-H): 🌀 endocervical sampling & colposcopy *LOW GRADE SQUAMOUS INTRAEPITHELIAL LESION* (LGSIL or LSIL): - CIN 1. - 50% of these cases are thought to regress within 2 years but 20% progress to HSIL. 0.2% turn into cancer. 🌀 repeat cytology or colposcopy in 6 months ❗*HIGH GRADE SQUAMOUS INTRAEPITHELIAL LESION* (HGSIL or HSIL):* - CIN II/CIN III 🌀 immediate colposcopy and biopsy 🌀 conisation of the cervix - if detected during pregnancy; revaluation with cytology and colposcopy 6 weeks after birth. *High-grade lesions discovered during pregnancy have a high rate of regression in the postpartum period*. Note: endocervical curettage and endometrial sampling are contraindicated in pregnant women. ❗*SQUAMOUS CELL CA* 🌀 colposcopy referral within 2 weeks *ATYPICAL GLANDULAR CELLS* not otherwise specified (AGC-NOS) 🌀 all women should have colposcopy 🌀 those aged>35 should have endocervical curettage *ATYPICAL GLANDULAR CELLS* - suspicious for AIS or cancer (AGC-neoplastic) 🌀 colposcopy within 2 weeks *ADENOCARCINOMA IN SITU* (AIS) 🌀 colposcopy referral within 2 weeks

*MENOPAUSE* <note: picture shows cervix visualisation for a postmenopausal patient complaining of painful sex and spotting: it shows vaginal and cervical atrophy>

*RULE OUT OTHER CAUSES WITH PATIENTS WITH S/S OF MENOPAUSE; e.g. HYPERTHYROIDISM* symptom management - HRT for vasomotor symptoms - oestrogen cream: for vaginal atrophy - SERM, biphosphonate and calcium supplementation for osteoporosis

*MITTELSCHMERZ* / OVULATION PAIN

- physical examination normal - one sided abdominal mild pain sharp/cramping that occurs @ time of ovulation.

*HRT PREPARATIONS* HRT preparations consist of daily oestrogen and with either - sequential (cyclic regimen): for perimenopausal women - daily (continuous combined regimen) progesterone added if necessary: for postmenopausal women remember: - if no uterus; don't give progesterone. Give oestrogen only HRT

*CYCLIC HRT* for women under 50 years; low dose combined oral contraceptives should be used in perimenopausal women to minimise irregular bleeding. There are two types: - *monthly HRT* which is usually recommended for women having regular periods. The second type is - *three-monthly HRT* recommended for women with irregular periods. Patient should have a period every three months. The oestrogen is taken every day, and progestogen alongside it for around 14 days every three months. 🔹 *Femoston* 1/10 to start with 🔹 *Premique* cycle 🔹 *Elleste* Duette *CONTINUOUS HRT* combined oestrogen progestogen therapy*: for 2 year postmenopausal women who wish to avoid bleeding 🔸*Kliofem* (norethisterone 1mg plus oestradiol valerate 2mg) 🔸*Premique* (0.625 mg oestrogen, 5 mg progestin) 🔸*Climesse* 🔸*Elleste* Duette Conti: (2mg oestrogen, 1mg progestin) *OESTROGEN ONLY* (for post hysterectomy) - *Elleste* Solo (tablet) - *Elleste* Solo MX (patch)

*CONTRACEPTION* Methods

*Combined contraceptive pill* - aims to inhibit ovulation - more than 99% effective but typically 91% - common brands include *Microgynon* and *Rigevidon* - other brands: *Cilest, Yasmin* - *Loestrin 20* contains less oestrogen; perfect for those who have risk factors but still want the combined pill. *Progestin-only pill* - higher failure rate than OCP if not used appropriately. Requires utmost compliance. - brands such as *Cerazette* - suitable for those where oestrogen contained contraception is contraindicated - take every day with no pill free period - no contraindications to taking *Contraceptive transdermal patch (Evra)* - more than 99% effective but typical use is around 91% effective - contains the *BOTH oestrogen and progestogen* - apply a new patch once a week, every week for three weeks (21 days). Then stop using the patch for seven days (patch-free week). *Contraceptive IM injection: Depo-Provera* - typical use: around 94% effective. - the injection lasts for *8 or 12 weeks*, depending on the type. - it *can take up to 1 year for fertility to return to normal after the injection wears off*, so it may not be suitable if the patient wants to have a baby in the near future. - periods may change and become irregular, heavier, shorter, lighter or stop altogether after stopping use - associated with decreased bone mass density; patients advised to consume foods rich in calcium and vitamin D. - absolute contraindication: liver disease *Contraceptive implant*: - >99% effective with perfect use. This is a *small flexible plastic rod* that's placed under the skin in the upper arm. They work for *three years* but can be taken out earlier. - it releases *progestogen only* preventing ovulation and thickening the cervical mucus - Fewer than 1 in 100 women using the implant will get pregnant in a year. - offer to those who don't plan on becoming pregnant for the next few years and have a history of poor compliance on the pill *Vaginal ring/pessary* - Perfect use: more than 99% effective - Typical use: around 91% effective - plastic ring that releases both oestrogen and progestogen *Intrauterine system (IUS) e.g. Mirena coil*: - >99% effective. A small *plastic T shaped device* that releases *progestogen* which thickens cervical mucus, inhibits sperm mobility and thins the endometrium (pretty much making it a hostile environment). - It can make *periods lighter, shorter or stop altogether/amenorrhoea (20% risk of amenorrhoea)*, so it may help women who have heavy or painful periods. Spotting may occur for 6 months and periods may be erratic but gradually the menstrual flow should become lighter... approximately 20% of women experience complete amenorrhoea. - works immediately if inserted within first 7 days of menstrual period otherwise, advised to take additional contraception. - An IUS normally works for *five years* but can be taken out earlier. - Fewer than 1 in 100 women will get pregnant over five years when using an IUS. *Intrauterine device (IUD)*: - more than 99% effective and works immediately from insertion. - a T shaped device that releases *COPPER* producing a spermicidal environment - An IUD can stay in place for 5 to 10 years depending on the type but can be taken out at any time. - first-line for emergency contraception; can be used <5 days of unprotected sex. It is considered first-line due to higher efficacy. - warn the patient that *periods may become heavier, longer or more painful* initially but this should improve after a few months. This is usually the most common reason for discontinuation - the *risk of ectopic pregnancy is higher* - it *doesn't protect against infections*. *Sterilisation (permanent contraception)* - Female sterilisation: more than 99% effective. Around 1 in 200 women will become pregnant in their lifetime after being sterilised. - Male sterilisation or vasectomy: around 1 in 2,000 men can become fertile again in their lifetime after a vasectomy. Typically under LA; procedure blocks tube that release sperm. It cannot easily be reversed *Male and female condoms* Male condoms - Perfect use: 98% effective. This means that 2 in 100 women whose partners use a condom will get pregnant in a year. - Typical use: around 82% effective. This means around 18 in 100 women will get pregnant in a year. Female condoms - Perfect use: 95% effective. About 5 in 100 women who use a female condom will get pregnant in a year. - Typical use: around 79% effective. Around 21 in 100 women will get pregnant in a year. *Diaphragms and caps* - Perfect use: 92-96% effective. Between 4 and 8 women in 100 who use a diaphragm or cap with spermicide will get pregnant in a year. - Typical use: around 71-88% effective. Between 12 and 29 women in 100 using a diaphragm or cap will get pregnant in a year. Natural family planning - Perfect use: can be up to 99% effective if the natural family planning methods are followed precisely. These include monitoring cervical secretions and your basal body temperature. It's more effective if more than one method is used and it's taught by specialist teachers. Up to 1 in 100 women will get pregnant in a year when using this method perfectly. - Typical use: around 76% effective. Around 24 in 100 women using natural family planning will get pregnant in a year.

*OVARIAN TUMOURS* *dermoid cyst/mature cystic teratoma* - most common ovarian tumour in 2nd-3rd decade of life and are almost invariably benign *granulosa cell tumour*

*DERMOID CYST* - diagnosis: presence of fluid filled/fat calcification, tufts of hair on CT are diagnostic. - complications: torsion (carries the highest morbidity), infection, rupture (rare), malignancy (v.rare) *GRANULOSA CELL TUMOUR* - the most common type of sex cord-stromal tumour associated with elevated oestrogen and/or progesterone production. - produce aromatase, which converts testosterone to estradiol. Excess production of oestrogen can cause *breast tenderness and menstrual abnormalities*. - unopposed oestrogen causes the endometrium to proliferate, resulting in abnormal uterine bleeding and an increased risk of endometrial adenocarcinoma.

Menstrual Period

*Day 1-3 PERIOD*: usually begins at 12-15yrs of age; first period is known as menarche - bleeding; the uterus sheds its lining and becomes thin. As soon at this ends, the uterus prepares again to receive a fertilised egg *WEEKS 1-2*: FSH released from pituitary to release OESTROGEN (which increases during this period) from the ovaries: this: - proliferative phase of uterine cycle: oestrogen causes endometrial thickening, increased vascularity and secretory glands production. It also helps with thinning of the cervical mucus to produce habitable environment for sperm - inhibits FSH production so that only one egg matures. - stimulates LH production surge around day 12 to help with ovulation. *Day 14: OVULATION*: egg released from ovary. - Once ovulation has occurred the hormones LH and FSH cause the remaining graafian follicle to develop into the corpus luteum. The corpus luteum then begins to produce the hormone PROGESTERONE. - Progesterone levels increase: stops growth and instead maintains the lining of uterus (secretory phase) making it a more habitual for the embryo to implant - oestrogen, LH and FSH levels decreases. A) As the levels of FSH and LH fall, the corpus luteum degenerates. B) This results in progesterone no longer being produced. C) The falling level of progesterone triggers menstruation (shedding of the functional endometrial layer) and the entire cycle starts again. Symptoms: abdominal pain/cramps, vaginal bleed, nausea, irritability. However if an ovum is fertilised it produces hCG which is similar in function to LH. This prevents degeneration of the corpus luteum (continued production of progesterone). 1) Continued production of progesterone prevents menstruation (shedding of the endometrial layer) and the patient will not have their period. 2) The placenta eventually takes over the role of the corpus luteum (from 8 weeks).

*BREAST LUMPS* *RED FLAGS* 🚩Hard, irregularly shaped lump 🚩Fixity of lump to skin or chest wall +/skin tethering 🚩Fixed axillary lymphadenopathy 🚩Bloody nipple discharge breast cancer screening (mammogram) is offered every 3 years for women age 50-70 WORKUP 1) age of patient + assess for red flags and if meets the criteria for referrals. 2) if no red flags: ask if any history of breast/ovarian ca, HRT, if breast feeding, when did they notice it? if they feel the mass more prior to menstruation; has it changed size? Topics - invasive ductal ca - inflammatory breast ca - Paget's disease - intraductal papilloma - fibroadenoma - fibrocystic changes - mastitis - galactocele - fat necrosis - others referral dictation example "thank you for seeing this 31 year old lady who presents with a painless non-tender hard solitary lump in her right breast. I'd be grateful for further investigations to rule out possible sinister causes"

*MALIGNANCY*: - invasive ductal carcinoma (80%) - more likely to occur after menopause - possible s/s: bloody nipple discharge, inverted nipple, skin changes (dimpling, rashes, ulceration), hard, irregularly shaped lumps with fixity - U/S guided core needle biopsy required for diagnosis *2-week referral* 🔥 aged >30 with unexplained lump: refer for U/S 🔥 aged >50 with any of the following in one nipple only: discharge, retraction or other changes of concern *consider (with risk factors) 2-week referral for*: 🕯️ age >30 with skin changes or an unexplained lump in the *axilla* *non-urgent referral* 🕯️ age <30yrs with an unexplained breast lump with or without pain (chances are it's just fibroadenoma). *PAGET'S DISEASE OF THE BREAST* - adenocarcinoma usually that infiltrates the nipple and areola - *erythematous, scaly, vesicular pruritic rash* affecting the nipple and areola - the lesion eventually ulcerates leading to a *blood-tinged nipple discharge* - differential: mammillary eczema *INTRADUCTAL PAPILLOMA* - solitary or multiple benign lesions that arise from the epithelium of breast ducts - peak incidence 40-50yrs - *most common cause of bloody nipple discharge* - if lesion palpable; requires core needle biopsy *FIBROADENOMA*: - *most common benign breast tumour in young women <35 years old*. - painful, firm, round, smooth, highly mobile rubbery lumps that may feel *tender especially prior to menstruation*. - mammogram: large and coarse popcorn calcifications. - may need referral for U/S guided FNA *FIBROCYSTIC CHANGES*: - most common benign lesion of the breast - occurs more commonly in *premenopausal women*. characterised by *tender, rubbery, irregularly shaped immobile lumps* that change in size similar to fibroadenomas. - premenstrual bilateral breast pain - refer for U/S *MASTITIS*: (see obstretics) - tender, firm, red, swollen, warm (inflamed area) of the breast, fever >38°C, flu-like symptoms, painful lump caused by a blocked duct - most common in lactating women occurring within the first 6-12 weeks after giving birth - management for lactating women: *warm compresses*, *warm water bathes*, to relieve pain and help milk to flow, rest, avoid wearing a bra at night, advise to *continue breastfeeding if possible* - treat: *flucloxacillin* 500 mg QDS for 10-14 days or *erythromycin/clarithromycin*; safe to use during pregnancy - warn patient to seek medical advice is s/s do not improve within 48 hours of antibiotics - if treatment fails, *consider breast abscess or cancer.* - management for non-lactating women: should receive *co-amoxiclav* 500/125 mg TDS for 10-14 days. Alternatively clarithromycin/erythromycin or metronidazole. *GALACTOCELE* - most common benign breast lesion in lactating women - painless, firm mass - mainly a clinical diagnosis otherwise refer for U/S *FAT NECROSIS* - associated with trauma (e.g. seatbelt injury) - rare, peaks @ 50yrs - irregularly defined mass with skin erythema - requires U/S for further evaluation *OTHERS* - *lipoma* (soft mass); non-infective mastitis ask patient their age, history of breast/ovarian ca, HRT, if breast feeding, when did they notice it? if they feel the mass more prior to menstruation; has it changed size?

Female Sex Hormones

*OESTROGEN* - responsible for growth and development of female secondary sexual characteristics; breasts, pubic and armpit hair, and the regulation of the menstrual cycle and reproductive system - FSH from pituitary gland simulates the ovaries to produce oestrogen. It can also be produced by other organs - At normal levels oestrogen prevents depression and insomnia , increases concentration, and maintains normal sex drive. If oestrogen is too high or low, depression, anxiety, insomnia, decreased sex drive and decreased concentration may result. Synthetic oestrogen: - Prevents the pituitary gland from producing FSH and LH so ovulation doesn't occur. - supports the uterine lining to prevent mid-cycle breakthrough bleeding. *PROGESTERONE* Progesterone is produced by the ovary after ovulation. It instructs the uterine lining to stop growing so that it might develop and mature in preparation for a possible pregnancy . Progesterone is produced for 14 days after ovulation. If there is no pregnancy, progesterone decreases and signals the beginning of menses. If there is fertilisation; production continues as to prevent menstruation Synthetic progestin: - causing cervical mucus to thicken, hindering the ability of the sperm to travel. - stop LH production from occurring in the pituitary gland so no egg is released. - cause changes to the uterine lining which make it harder for an egg to implant.

*INCONTINENCE* (see symptoms seen in GP for better explanations) - overflow - stress - urge - mixed

*OVERFLOW*: involuntary loss of urine secondary to pressure of a full bladder. Occurs in those with pathological obstruction e.g. BPH, prostate ca, medication side effect. ==> management: treat underlying cause, intermittent catheter if needed *STRESS*: involuntary leakage due to increased abdominal pressure. Leakage of urine on exertion e.g. cough. Risk factors include pregnancy, vaginal delivery, obesity. ==> management: pelvic floor muscle exercises (for <60yrs age), weight loss, regular micturition *URGE*: sudden urge secondary to odd bladder contraction; causes: stones, neurological pathology. ==> management: bladder training and anticholinergics e.g. oxybutynin diagnosis - urodynamic testing is gold standard

*AMENORRHOEA* (no menstrual cycle) causes and workup *primary amenorrhoea*: - no menses by age 13 in absence of secondary sexual characteristics or - no menses by age 16 with secondary sexual characteristics present or - no menses 2 years after the-larche (boobs stage of puberty) *secondary amenorrhoea* - no menses for >6 months or 3 cycles after documented menarche workup for amenorrhoea 1) assess age, LMP (if any), physical: Tanner scale and presence of secondary sexual characteristics 2) rule out *PREGNANCY* (hCG) 3) add onto bloods TSH (hypothyroidism), prolactin, FSH/LH (helps determine if central or peripheral cause), *androgens (free testosterone, DHEA) 3) if primary amenorrhoea: x-ray of wrists: bone age delayed compared to chronological age with ↑LH and normal MRI indicates constitutional cause. 4) bloods: check basal LH and FSH ➖ if ↓LH+FSH: ↓GnRH production - *CONSTITUTIONAL DELAY* (if primary amenorrhoea) - *ATHLETIC🏃‍♂️, MALNUTRITION🍔, ANOREXIA NERVOSA, CNS TUMOUR, KALLMAN SYNDROME* ➖ if ↑LH+↓FSH: in a 3:1 ratio: likely *PCOS*: confirm with pelvic U/S, amenorrhoea, hyperandrogegism (acne, oily skin, acanthosis nigricans) with normal pubertal changes ➖if ↑/normal LH+FSH: peripheral cause - bloods (rule out *ANDROGEN INSENSITIVITY, CF, COELIAC DISEASE, DIABETES, KIDNEY DISEASE*) - pelvic U/S (*PCOS, MULLERIAN AGENESIS*) - karyotype (*TURNERS, KLINEFELTER'S*) - genetic: (*KALLMANN SYNDROME*) 5) in the case of primary amenorrhea, measure also TSH and prolactin

*primary amenorrhoea*: - no menses by age 16 with secondary sexual characteristics - no menses by age 13 with absence of secondary sexual characteristics 💡 *primary amenorrhoea* + *no secondary sexual characteristics* *CONSTITUTIONAL DELAY*: - hypogonadotropic hypogonadism - ↓LH and ↓FSH - amenorrhoea + absence of secondary sexual characteristics *GONADAL DYSGENESIS* - hypergonadotropic hypogonadism - ↑LH + ↑FSH - congenital developmental disorder whereby the gonads are replaced by fibrous tissue e.g. *Turner's syndrome*: XO: missing X chromosome: causes early loss of ovarian function and thus no puberty and there will be loss secondary sexual development. 💡*primary amenorrhoea* + *presence of secondary sexual characteristics* *MULLERIAN AGENESIS* (XX karyotype) - congenital malformation characterised by failure of the Müllerian duct to develop, resulting in a *missing uterus and variable degrees of vaginal hypoplasia and ambiguous genitalia*. - external genitalia may be normal and secondary characteristics are present. - the most appropriate tests to confirm include *serum testosterone, dihydrotestosterone and karyotype* + U/S pelvis. *IMPERFORATE HYMEN* (XX karyotype) - congenital disorder where a hymen without an opening completely obstructs the vagina. It is caused by a failure of the hymen to perforate during foetal development. - most often diagnosed in adolescent girls when menstrual blood accumulates in the vagina and sometimes also in the uterus. - perineal exam reveals a *suburethral bluish bulge with rectal exam* showing midline fullness. *ANDROGEN INSENSITIVITY SYNDROME* (XY karyotype) - genetically male, but the external appearance of their genitals may be female (complete). or somewhere between male and female (incomplete). - complete androgen insensitivity syndrome is often not diagnosed until puberty, when periods don't start and pubic and underarm hair doesn't develop. - there are *no internal female reproductive organs on U/S scan* - differentiate with mullerian agenesis with testosterone levels and karyotype. *CONGENITAL ADRENAL HYPERPLASIA* - ambiguous genitalia at birth and heterosexual precocious puberty - *functional hypothalamic amenorrhoea*: >>> SECONDARY AMENORRHOEA <<< (see general s/s in GP for more information) >> rule out natural physiological changes such as *pregnancy (positive hCG), lactation, stress, menopause* >> endocrinology causes: *POLYCYSTIC OVARIAN SYNDROME* - 30% of cases detected of all cases detected in late teenage years - *oligomenorrhoea* or *amenorrhoea* - *high androgen levels* - testosterone (clinical symptoms of infertility, obesity, acne, hirsutism, male patterned baldness). Total testosterone levels should be repeated if initial test is negative; ideally done in the morning - *polycystic ovaries on USS* - *acanthosis nigricans*, *LH>FSH 3:1* - increased risk of cardiovascular disease and endometrial ca management 1) encourage weight loss/exercise 2) *OCP* (regulates menstruation and are first line: they held reduce circulating androgen levels) - progestogens (induce a withdrawal bleed if oligomenorrhoea) 3) *co-cyprindiol*: (reduces acne and hirsutism) 4) *clomiphene* (induces ovulation) 5) *metformin*: (insulin sensitivity and infertility) *PREMATURE OVARIAN FAILURE* - ovaries produce insufficient levels of oestrogen: 1/3 as a result from autoimmune disorders like Addison's disease, type 1 diabetes, Hashimoto's thyroiditis. Classic triad of - amenorrhoea - high FSH and LH - low oestrogen >> secondary ovarian failure: a result of inadequate gonadotropin stimulation of the ovary from: - *hyperprolactinaemia* (secondary to pituitary adenoma. Remember associated s/s of headaches, bitemporal hemianopsia and galactorrhea - excessive milk production is commonly associated), - *Cushings' syndrome*: cortisol levels high - *anorexia nervosa* - *excessive exercise* - *depression, drugs* >> physical/previous surgery - *Asherman's syndrome*: associated with extensive curettage and dilation; adhesions of the uterus result. Hormonal levels are normal. *workup* (toronto notes) 1) if suspecting primary amenorrhoea; perform pelvic USS 2) if suspecting secondary amenorrhoea: - *β hCG* to rule out pregnancy - *TSH*: to rule out hypothyroidism - *prolactin*: perform CT head if result is >100: to rule out hyperprolactinaemia secondary to pituitary adenoma - *FSH, LH*: high levels indicate ovarian failure (peripheral cause) or premature menopause. Low levels indicate a central cause. - *androgens (free testosterone, DHEA)* may suggest PCOS - *oestradiol*: low levels indicate ovarian failure. 3) *progesterone challenge* to assess oestrogen status ■ Provera® 10 mg PO OD for 10-14 days: any uterine bleed within 2-7 d after completion of Provera® is considered to be a positive test/withdrawal bleed ◆ withdrawal bleed confirms lack of progesterone but presence of adequate enough oestrogen to thicken the endometrium; thus withdrawal of progesterone results in bleeding. Check FSH/LH levels: ---> if high, it could be PCOS. ---> if normal/low: HP axis dysfunction: ideal to perform MRI. ◆ if no bleeding occurs 4) perform the *oestrogen-progesterone challenge* - if still no withdrawal bleed: outflow obstruction should be suspected most commonly from Asherman's disease secondary to previous operations on the uterus; aim to treat intrauterine adhesions with hysteroscopy and lysis. - if withdrawal bleed: deficiency of both hormones suggest primary ovarian insufficiency/premature ovarian failure; this is loss of normal function of the ovaries before age 40. In 33% of cases; the cause is due to other autoimmune disorders. Other causes include chromosomal abnormality, infections e.g. mumps, CMV or varicella. - *karyotype*: indicated if primary ovarian insufficiency or absent puberty - *U/S*: to confirm normal anatomy and to identify PCOS

*CERVICAL CANCER* <image shows abnormal speculum examination of the cervix indicating malignancy> 1) abnormal pap smear --> test for HPV+ 2) if suspicious: perform colposcopy 3) if suspicious cells, perform colposcopy biopsy 4) if biopsy bad --> treat accordingly: LLETZ, cone biopsy, cryotherapy, laser therapy, coagulation

*risk factors*: smoking, high parity, multiple sex partners, low socioeconomic status *causes*: HPV 16, 18 causing squamous cell carcinoma. Very small amount of causes involve herpes *symptoms*: most asymptomatic but in advanced cases; irregular vaginal bleeding which can occur during or after sex. Commonly diagnosed at age 45-50. *screening with pap smear* - women aged 25 to 49 (21-65 for Canada) are offered screening every 3 years and those aged 50 to 64 are offered screening every 5 years. (21-65 for Canada) - ideal to be performed 10-20 days after the start of the last period. - results (A) ASCUS: atypical squamous cells - undetermined significance means that the lab will follow up with HPV testing (B) borderline change in squamous or endocervical cells, or low-grade dyskaryosis and HPV+ means referral for colposcopy + biopsy within 6 weeks (C) high grade dyskaryosis: refer for colposcopy + biopsy within 2 weeks next stage is: *colposcopy*: if pap test result shows abnormal cells: this is a direct observation with a magnifying glass. Acetic acid is applied to directly visualise abnormal cells. If abnormal area seen; a biopsy is taken; this is then classified as CIN *management if abnormal colposcopy biopsy result* - large loop excision of the transformation zone (LLETZ): removal of cells with thin hot looped wire - cone biopsy: less commonly done: cone removal of abnormal cells - others: cryotherapy, laser therapy, cold coagulation: for low grade dysplastic lesions of the cervix - if early cervical cancer: radical hysterectomy - if spread: RTx and chemotherapy *prevention* - routine pap smears - HPV vaccine (Gardasil) in both teenage girls and boys >> in Canada <<: those who can receive the HPV vaccine include: - girls aged 9 to 45 - all boys and young men between the ages of 9 and 26 >> in the UK <<: - girls and boys 12-18 years of age: usually 2 doses however, if older than 15; will need 3

*DIFFERENTIAL FOR YOUNG WOMAN PRESENTING WITH ACUTE PELVIC PAIN* - *acute appendicitis*: abdominal pain, fever, nausea, vomiting, etc - *ovarian torsion*: excruciating unilateral pain +/- adnexal mass on palpation. Usual associated symptoms; nausea, vomiting, low grade fever. Occurs in reproductive age. Other risk factors include: previous episode, ovulation induction, ovarian mass and pregnancy. - *ectopic pregnancy*: period of amenorrhoea followed by severe unilateral pelvic pain + shock (if rupture) . Rule out with hCG and transvaginal U/S. - *ruptured ovarian cyst*: can cause peritoneal signs + hypovolaemic shock - *tubo-ovarian abscess* - *vulvovaginitis* - *pelvic girdle ligament relaxation* in late pregnancy can cause pelvic + lower back pain worsening and lasting weeks

- *acute appendicitis*: abdominal pain, fever, nausea, vomiting, etc - *ovarian torsion*: excruciating unilateral pain +/- adnexal mass on palpation. Usual associated symptoms; nausea, vomiting, low grade fever. Occurs in reproductive age. Other risk factors include: previous episode, ovulation induction, ovarian mass and pregnancy. - *ectopic pregnancy*: period of amenorrhoea followed by severe pelvic pain. Rule out with hCG - *ruptured ovarian cyst*: can cause peritoneal signs - *tubo-ovarian abscess* - *pelvic inflammatory disease*: fever, dyspareunia, post-coital bleeding, history of multiple partners, etc. - *vaginal dryness*: common in post-menopausal women complaining of dyspareunia. Manage with topical oestrogen cream. - others: diverticulitis, IBD exacerbation, workup - history/physical - urine c&s, swabs - bloods: FBC, BCP, CRP - U/S abdomen/pelvis

*BREAKTHROUGH BLEEDING* - abnormal uterine bleeding between menstrual periods in women who use the OCP is called BTB and is associated with insufficient oestrogen

- bleeding/spotting that occurs within the cycle (outside the periods) - caused by those 3 months after initiating the OCP, those who miss the COC pill or take combinations with lower oestrogen level - main cause of BTB is attributed to insufficient oestrogen so endometrial integrity cannot be sustained - if experiencing BTB for >3 months; ideal management would be to start NSAIDs and/or supplemental oestrogen for 1-2 weeks then follow up. If still no improvement, change pill formation to either higher oestrogen or different progestin. If still no improvement, try another form of contraception.

*LICHEN SCLEROSUS*

- cause unknown; most likely autoimmune - progressive inflammatory condition leaving itchy white patches on the genitals or other parts of the body. - common in postmenopausal women; vulva and anus. Can also occur on the foreskin in men. - treatment of choice: potent steroid cream e.g. clobetasol.

*VAGINAL PROLAPSE* A *cystocele* is a bulge in the front wall of the vagina, which allows the bladder to move downwards into the bulge. A *rectocele* is a bulge in the back wall of the vagina, which allows the back passage (rectum) to move downwards into the bulge. An *enterocele* is a less common type of prolapse in which the top end of the vagina bulges down into the vagina, allowing the small bowel to drop into the bulge. Most commonly due to previous hysterectomy. Obliterate the cul-de-sac would help improve

- different types: cystocele, rectocele, enterocele and vault prolapse. - involves herniation of the peritoneal sac between the vagina and the rectum. When the muscles and tissues supporting the pelvic organs (the uterus, bladder, or rectum) become weak or loose. This allows one or more of the pelvic organs to drop or press into or out of the vagina risk factors: previous pelvic surgeries, multiparity, increasing age, obesity pulling sensation in the pelvis or low back pain that worsens in the evening but eases up when lying down. A sensation of a mass bulging into the vagina It is caused by increased pressure on the pelvic floor e.g. pregnancy, childbirth, chronic constipation. management: - if asymptomatic; try pelvic floor muscles, vaginal pessaries, exercise, avoid smoking - surgical repair

*CHRONIC PELVIC PAIN DIAGNOSTIC WORKUP*

- history and examination - urinalysis and culture - cervical swabs for gonorrhoea and chlamydia - FBC, ESR, beta-hCG levels - U/S pelvis - diagnostic laparoscopy if all else unexplained

*ADNEXAL MASS FINDING*

- mass corresponding to the ovaries of fallopian tubes - most common cause in reproductive age is a functional cyst (follicular or corpus luteum); these are thin walled and usually resolve or rupture spontaneously. Any cystic mass <6cm can be followed up in 2 months with repeat U/S - if mass persists; request a laparoscopy

*ENDOMETRIAL CANCER*

- most common cause for postmenopausal bleeding risk factors: - PCOS (most common) - obesity (increases endogenous oestrogen) - prolonged exposure to oestrogen (nulliparity, late age of menopause, early menarche - white race - breast cancer, tamoxifen, - systemic disease: diabetes, HTN, gallbladder disease, staging IA: less than halfway through myometrium IB: spread halfway or more into myometrium II: spread to cervix III: spread to nearby areas in the pelvis: fallopian tubes, ovaries, vagina, para-aortic nodes IV: beyond to bladder, bowel management: radical hysterectomy, bilateral salpingo-oopherectomy and radiotherapy

*GENITAL WARTS*/*CONDYLOMA ACUMINATA*

- pruritic cauliflower-shaped papules on the vagina secondary to HPV 6,11 from unprotected sex - diagnosis is clinical - biopsy performed if any of the following: diagnosis uncertain, doesn't respond to therapy, atypical, warts are pigmented/indurated, fixed, bleeding or ulcerated - usually 50% resolve within 4 months without treatment and 75% disappear within 2 years - treatment with lowest rate of recurrence is surgical excision

*PELVIC INFLAMMATORY DISEASE* - polymicrobial disease of the upper genital tract

- typically young women; sexually active, multiple sex partners, history of unprotected sex *cause* by STDs: mainly chlamydia and gonorrhoea *symptoms*: fever, dyspareunia, post-coital bleed, abnormal vaginal discharge, lower abdominal pain *manage*: refer to GUM for full screening and contact tracing. Obtain swabs if there's delay *- ceftriaxone single IM + 14 days of doxycycline and metronidazole* - ofloxacin + metronidazole for 14 days (remember that metronidazole in contraindicated in breastfeeding mothers OR - if pregnant; admit the patient and give IV cefoxitin/cefotetan and azithromycin (instead of doxycycline) - clindamycin and gentamycin is also an alternative; can be used with breastfeeding mothers. - if haemodynamically unstable and/or presents with acute abdomen: prep for immediate laparoscopy. - complications: sepsis/abscess, ectopic pregnancy, increased recurrency risk, Fitz-Hugh-Curtis syndrome (spread to the peritoneum causing inflammation/scarring of the liver).

*BACTERIAL VAGINOSIS* - non-STD infection

- typically young women; sexually active, multiple sex partners, history of unprotected sex, douching, IUD, recent antibiotics - caused by the overgrowth of existing bacteria in the vagina e.g. lactobacillus. - symptoms: asymptomatic in 50% otherwise fishy odour, grey/thin creamy discharge - manage: obtain swabs if recurrent otherwise metronidazole PO or clindamycin 2% cream for 7 days. Advise simple measures: avoid products bath products like shampoo and use water/plain soap to wash your genital area. Shower instead of bathing, avoid douches. - complications: small risk of preterm delivery/miscarriage, PID, endometritis

*STDs* 1) chlamydia 2) gonorrhoea 3) trichomonas

1) *CHLAMYDIA*: obligate intracellular organism, vaginal PH acidic, nucleic acid amplification required for diagnosis. - treat with *azithromycin* 1g first line or doxycycline (but contraindicated in pregnancy) 2) *GONORRHOEA*: gram negative intracellular diplococci: refer to local GUM clinic. - purulent creamy vaginal discharge - treatment involved *IM ceftriaxone 250 mg with oral doxycycline*; both of which are single doses. 3) *TRICHOMONAS*: flagellated protozoa on wet mount: frothy, green/yellow vaginal discharge, vulvovaginal itching, soreness, dysuria, dyspareunia and abdominal pain. Whiff test positive. Specifically on vaginal examination: *colpitis macularis*: strawberry cervix. (think s*TR*awberry - TRichomonas). Treat with *oral metronidazole*

*HORMONE FUNCTIONS*

1) *OXYTOCIN*: uterine contractions, contraction of the ducts to *eject* milk from the nipple 2) *PROLACTIN*: stimulates alveolar cells to *produce* milk 3) *PROGESTERONE*: released from the ovaries (and later the placenta) helping to stimulate the development of these breast tissue glands. Main function is to regulate the condition of the endometrial lining. 4) *OESTROGEN*: released from the ovarian follicles; promotes breast growth ducts, helps development of secondary sexual characteristics and stimulates endometrial growth. 5) *HUMAN PLACENTAL LACTOGEN*: modifies the metabolic state of the mother during pregnancy to facilitate the energy supply of the foetus

*INFERTILITY (GENERALLY)* causes: *infections, age>35, lifestyle and diseases* - 85% conceive within 1 year of regular unprotected sex, 95% within 1 year - If history/examination, age>36, day21 bloods (progesterone) abnormal; refer to fertility clinic.

1) counselling ➖ aim for unprotected sex 2-3x/week for at least 12 months especially just before ovulation. ➖ discuss lifestyle factors: smoking, alcohol, cocaine, marijuana, improper diet, medications (contraceptives, NSAIDs, antipsychotics, spironolactone, chemotherapy), lack of exercise. Others: stress, anxiety. ➖ advise on a *urinary 5 sticks LH kit*. ↑LH surge occurs 14 days before next cycle e.g. if a woman's menstrual cycle is 35 days; her LH surge should be expected at 21 days. The kit allows the woman to time intercourse to maximise chances of becoming pregnant. They should use this a few days before e.g. in this case; 18th day 2) rule out from history: ➖ woman; LMP, any irregular periods and/or bleeding, current use of contraception ➖*pelvic inflammatory disease* in both partners, If suspected; perform urethral discharge swabs for *STDs* (chlamydia and gonorrhoea) gram stain and culture. Empirical treatment includes ceftriaxone IM 250mg + doxycycline +/- azithromycin (gonorrhoea). - note: avoid doxycycline in pregnancy or attempting to become pregnant. 3) identify MALE pathology ➖ examine for *varicocele* ➖ Kallman syndrome: characterised by delayed onset of puberty and hyposmia/anosmia. Often associated with structural/developmental abnormalities: cryptorchidism, cleft palate, scoliosis, renal agenesis ➖ perform a *sperm* analysis (35% cause). - if sperm abnormal; work up for chromosomal karyotyping e.g. Klinefelter's or Turner's. If sperm analysis normal follow the next steps: 4) FEMALE: work up for anovulation (20%) ➖ bloods: prolactin, androgen, FSH and TSH; high levels indicate ovulatory dysfunction. Furthermore; progesterone @ 3-5 days of the period (levels should be high). ➖ U/S or hysterosalpingogram to rule out for tubal, uterus or cervix *anatomical abnormalities*, *fibroids*, *PCOS* or *adhesions* (e.g. from surgery, Asherman's syndrome), reversal of vasectomy. => if *ovulatory dysfunction*: clomiphene can be used to trigger ovulation (SERM: inhibits hypothalamic oestrogen receptors thereby blocking the negative feedback effect of circulating endogenous estradiol. This results in an increase in the pulsatile secretion of GnRH and subsequent increase in both FSH and LH, stimulating ovulation). 6) consider genetic factors e.g. *Turner's syndrome, hyperprolactinaemia*

DEFINITIONS 1) menorrhagia 2) dysmenorrhoea 3) amenorrhoea 4) dyspareunia 5) irregular period 6) regular period 7) anovulation 8) oligomenorrhoea 9) mastalgia

1) heavy menstrual bleeding: ≥80 cc of blood loss per cycle or ≥8 d of bleeding per cycle or bleeding that significantly affects quality of life. Remember the following: - usual length of menstrual bleeding (period) is four to six days. - usual amount of blood loss per period is 10-35 ml. Each soaked normal-sized tampon or pad holds a teaspoon (5ml) of blood . That means it is normal to soak 1-7 normal-sized pads or tampons ("sanitary products") in a whole period 2) painful periods/menstrual cramps 3) no periods 4) difficult or painful sexual intercourse 5) cycle to cycle variability of ≥20 days. e.g. a woman has a cycle every 21 days; her next cycle suddenly becomes longer at 42 days. The start of a period is counted on the 1st day of menses. The length lasts till the first 1st of the next period where menses occurs. 6) a normal cycle lasting between 21-35 days 7) when the ovaries do not release an oocyte during a menstrual cycle; commonly associated with PCOS. 8) regularly has a period of >35 days: most commonly due to contraception, athleticism, anorexia, diabetes, hypothyroidism, high prolactin levels, antipsychotics, antiepileptics. 9) breast pain; generally classified as either cyclical (associated with menstrual periods) or noncyclic

*INFECTIONS* 1) herpes simplex 2) HPV 6,11 - genital warts 3)

1) herpes simplex - multiple, painful shallow ulcerations causing dysuria if vulva involved. Fever, malaise, tender regional LN. - tzank smear: multi nucleated giant cells and eosinophilic intranuclear inclusion bodies 2) HPV 6,11 --> genital warts/condyloma acuminata - cauliflower like papules on the genitals - diagnosis: whitening after 3% acetic acid (acetowhitening) application is noted - home remedies include: imiquimod 5% cream (best as recurrency rate is lower), podofilox and sinecatechins ointment; continue for a maximum of 16 weeks until lesions disappear. - applied by a physician: podophyllotoxin - physical ablative methods including cryotherapy (best initial treatment with good clearance rate at 3 months), excision, or electrocautery are better suited to keratinised warts

*ASHERMAN'S DISEASE*

Asherman's disease is amenorrhoea secondary to uterine adhesions secondary to previous operations on the uterus - oestrogen and progesterone response challenge shows no withdrawal bleed indicating some form of outflow obstruction - direct treatment involves with *lysis with hysteroscopy* - recurrence risk is reduced by placing a *foley balloon catheter* and applying *hyaluronic acid gel* to keep the walls of the uterus separated.

*EMERGENCY CONTRACEPTION*

Remember the 3 forms of emergency of contraception *ORAL LEVONORGESTREL/DESOGESTRAL* - effective if taken within 72 hours (3 days) of unprotected intercourse and may also be used between 72 and 96 hours after unprotected intercourse. - double the usual dose if patient on a CYP3A4 enzyme inducer such as carbamazepine. *ULIPRISTAL ACETATE* - a progesterone receptor modulator, is effective if taken within 5 days of unprotected intercourse. *INTRAUTERINE COPPER DEVICE* - can be inserted up to 5 days after unprotected intercourse and it is more effective than oral levonorgestrel for emergency contraception. - cover with antibiotic prophylaxis e.g. azithromycin. - not ideal in suspected cases of rape/sexual abuse due to the risk of STDs.

*VULVOVAGINAL CANDIDIASIS (THRUSH)*

SYMPTOMS ➟ white cottage cheese discharge ➟ intense pruritus ➟ stinging/soreness/burning during sex/peeing RISK FACTORS - most commonly in reproductive age: pregnancy, diabetes, obesity, immunocompromised, OCP, antibiotics INVESTIGATIONS - wet mount test: *pseudohyphae and spores* MANAGEMENT ↪ try *topical clotrimazole* 1% or 2% applied 2-3 times a day for 7-14 days and advise to come back if s/s persist. ↪ try using *fluconazole orally* (check BNF); especially if >4 episodes/year. Also indicated in balanitis (glans penis inflammation). ↪ *conservative* - avoid soaps, cleanse with water only - dry the affected area after washing - wear cotton underwear, loose fit clothes - take showers instead of baths ↻ IF RECURRENT vulvovaginal candidiasis - be sure to obtain swabs; could the cause be bacterial instead? - urine dip +/- culture and sensitivity - an immune deficiency? diabetes/antibacterial therapy/pregnancy/OCP; be sure to check bloods - if >4 episodes/year; treat with fluconazole treatment - if pregnant: avoid oral anti-fungal therapies. Give clotrimazole cream is ideally used first for 7-14 days. - if non-pregnant: you can give one-off dose of fluconazole 150mg DIFFERENTIAL - vulvar lichen planus - chronic candidiasis - contact dermatitis - atrophic vaginitis - vaginal adenosis

*GALACTORHOEA* - inappropriate lactation/increase in prolactin secretion; milky discharge from the nipples

causes: mainly *hyperprolactinaemia* from: - physiological: pregnancy, lactation, stress - cerebral tumour - systemic disease: hypothyroidism, CKD, liver failure - side effects of medications: antipsychotics, antidepressants, antihistamines, antihypertensives, illicit drugs

💊 THE ORAL CONTRACEPTIVE PILL 💊 Microgynon - ethinylestradiol 0.03mg levonorgestrel 0.15mg Rigevidon - ethinylestradiol 0.03mg levonorgestrel 0.15mg Loestrin - ethinylestradiol 0.03mg norethisterone acetate 1.5mg Yasmin - ethinylestradiol 0.03 drospirenone 3mg Cilest - ethinylestradiol 0.035mg norgestimate 0.25mg

contains artificial versions of female hormones oestrogen and progesterone oral contraceptives suppress ovulation (egg release) by inhibiting the LH surge prior to event ☝️ *reduces painful periods* (dysmenorrhoea). ☝️ *regular, shorter and lighter periods* (and frequently a decrease in menstrual cramps). ☝️‍*protects against pregnancy* with >99% efficiency if used properly without missed pills ☝️ *protects against ovarian, endometrial and colon cancer* however they are associated with a small risk of breast and cervical cancer :-( ☝️*protects against developing PID* instructions: - take one every day for 21 days, then stop for 7 days, and during this week there should be a period-type bleed. You start taking the pill again after 7 days. - taken at the same time every day. - best time to start is between the 1st and 5th day after your period as this offers immediate protection and is in sync with the cycle and avoids problems like intermenstrual spotting but overall; it depends on what is most convenient for you. Warn that: - efficiency depends on *compliance*, if *pill missed* and if *taking other meds such as anti-epileptics* - *does not protect against STDs*; so condom should still be used. - associated with a *small risk of breast and cervical cancer*; however, 10 years after stopping the pill, the risk of breast cancer goes back to normal. - it can cause temporary side effects at first, such as *headaches, nausea, breast tenderness and mood swings* - if these do not go after a few months, it may help to change to a different pill - it can *increase in blood pressure* predisposing to clots: DVT, PE, stroke, heart attack. - *breakthrough bleeding (BTB) and spotting (mid-cycle bleed)* is common in for the first few cycles after using the pill. - When on the pill, there is no actual period bleed as the body thinks its pregnant; instead, the 7 day period was implemented purposely as to cause a *withdrawal bleed* caused when the uterine lining breaks down. unsuitable/high risk for: - aged>35 who smoke 🚬 or have smoked <1yr 🚬 - BMI>35 - family history of clots - family history of breast cancer - CVD: hypertension (BP>140/90 on consecutive times), diabetes, IHD - severe migraines especially with aura - postpartum <6 weeks; can interfere with milk with breastfeeding - pregnancy (as it won't do anything)

*POLYCYSTIC OVARIAN SYNDROME* (PCOS) - unknown cause but thought to be linked with increased insulin secondary to genetics and/or obesity, adhesions from previous laparotomy - usually symptoms occur in late teenage years

DIAGNOSIS >2 of the following - *oligomenorrhoea* or amenorrhoea - *high androgen levels* - testosterone (clinical symptoms of infertility, obesity, acne, hirsutism, male patterned baldness). Total testosterone levels should be repeated if initial test is negative; ideally done in the morning - *polycystic ovaries on USS* others: - note also if performed: LH>FSH would be 3:1 COMPLICATIONS - infertility - raised LDL --> increased risk of cardiovascular and cerebrovascular disease - insulin resistance --> acanthosis nigricans, diabetes, endometrial ca MANAGEMENT - be sure to obtain lipid levels and HbA1c - encourage *weight loss*/exercise - if oligomenorrhoea: *progestogens* to help induce a withdrawal bleed - *OCP*: regulates menstruation - *co-cyprindiol*: to reduce acne and hirsutism - *clomiphene*: helps induce ovulation - *metformin*: helpful for insulin sensitivity and infertility

HRT

Hormone replacement therapy aims to replace oestrogen in the postmenopausal woman and therefore improve vasomotor symptoms when oestrogen levels drop type of HRT will depend on: ➯ *hysterectomy* - require oestrogen only therapy note: if a uterus is present, a progestogen must be included to avert the consequences of prolonged exposure to unopposed oestrogen. ➯ the *menopausal status* - *peri*menopausal women should be offered sequential therapy using *DAILY* oestrogen and *CYCLICAL* progestogen (if uterus present). - *post*menopausal women can be offered continuous combined therapy using DAILY oestrogen and DAILY progestogen ➯ preference for type of treatment: oral or not ➯ past medical history ➯ current medication ➯ age of menopause. Generally for women with menopausal symptom who are: - <50 years - HRT should be offered since the benefits far outweigh the risks - between 50 and 60 years - the benefits of HRT outweigh the risks - >60 years - risks tend to outweigh the benefits absolute contraindications - liver disease - undiagnosed vaginal bleeding - venous thrombosis - known/suspected breast or endometrial cancer

*BACTERIAL VAGINOSIS* - caused by an imbalance of the naturally occurring bacteria in the vagina; certain bacteria start to overgrow causing infection. - caused by Garderella vaginalis

SYMPTOMS OF VAGINAL DISCHARGE ➟ white/grey with *strong fish odour* ➟ thin and watery ➟ RARELY ITCHING occurs. Absence of vulva irritation RISK FACTORS - using soaps/shampoos in bath, improper drying of area, tight/occlusive clothing - IUD - vaginal douching: (vaginal irrigation) - multiple sexual partners - not using condoms DIAGNOSIS - whiff test: positive if fishy odour after addition of KOH - clue cells on microscopy TREATMENT ↪ oral *metronidazole* is first line: can also be used in pregnancy: 400mg BD for 5 to 7 days ↪ intravaginal *metronidazole gel 0.75%* once a day for 5 days (off-label for women aged less than 18 years), or intravaginal clindamycin cream 2%* once a day for 7 days. COMPLICATIONS - 2nd/3rd premature labour and birth - postpartum endometritis - rarely: PID DIFFERENTIAL - bacterial: grey, thin, watery discharge with fishy smell particularly after intercourse. Itching is rare. Whiff test positive, clue cells on microscopy. - candida: white cottage cheese, burning/itching. Wet mount test: pseudohyphae and spores - trichomonas: green/yellow discharge, itching, soreness, dysuria, dyspareunia and abdominal pain. Whiff test positive, strawberry cervix

*CONTRACEPTION* Advice

When prescribing for women of childbearing potential, consider the following questions: 1. Is she already pregnant? 2. Is she trying to become pregnant? 3. Is she at risk of an unplanned pregnancy? 4. Is she actively avoiding conception through contraception? A patient is unlikely to be pregnant if: - reliable method of contraception used properly - no unprotected sexual intercourse since last period - <7 days after start of normal period; <4wk post-partum, <7 days post-termination/miscarriage - fully breastfeeding, amenorrhoeic + <6mo postpartum if in doubt; pregnancy test >3 weeks after the last unprotected sexual intercourse. EFFICACY DEPENDS ON COMPLIANCE: 1) what is most convenient for them 2) do they have medical problems that would put them at higher risk of complications; i.e. oestrogen 3) how long do they want it to last? do they plan to have kids in the future? 4) method: pill? patch? intrauterine invasive device? injection? implant?

*VACCINATIONS* before/during pregnancy advice

as well as the routine immunisations such as tetanus and polio, pregnant women should have immunity against hepatitis B, measles, mumps, rubella, chickenpox, whooping cough and influenza. *BEFORE PREGNANCY* • *MMR*: advise to *wait four weeks after receiving this vaccine before trying to get pregnant*. • *chickenpox (varicella)*: If not protected; 2x doses of the vaccine for full immunity. Again, *wait four weeks after receiving this vaccine before trying to get pregnant*. • Protection against serious illness caused by pneumococcal disease is recommended for smokers and people with chronic heart, lung or kidney disease, or diabetes. *DURING PREGNANCY* - *influenza* in the 3rd trimester OR as soon as possible after the baby is born - *Tdap*: in the 3rd trimester to protect against whooping cough - *hepatitis B*: if mother is infected *DURING BREASTFEEDING* - all vaccines can be given to breastfeeding mothers, and having immunity will reduce the likelihood of passing on these illnesses to the baby

*PAINFUL PERIODS/DYSMENORRHOEA* CHRONIC PELVIC PAIN *Primary Dysmenorrhea* - recurrent cramps lower abdominal pain during menses in the absence of demonstrable disease - normal due to wound muscle contraction *Secondary Dysmenorrhea*: PAIN DURING MENSES that can be attributed to an underlying disorder - PID - endometriosis, adenomyosis - fibroids

ask about - periods: last period? regular/irregular? - sex: sexually active? any pain? or bleeding after sex (post-coital) - thick/foul smelling vaginal discharge? fever? - using an IUD; in the first 3 months? *SECONDARY* - investigate cause if red flag symptoms present (see above) - bimanual examination - U/S, laparoscopy and hysteroscopy screening for infections (vaginal and cervical cultures) may be required *PRIMARY* - re-assure patient most of the time; painful periods are *normal due to wound muscle contraction* that encourages the endometrial lining to shed away - advise to reduce pain with exercise, warm bathes/showers, massage, NSAIDs (before onset of pain) and use of combined OCP. You could also offer pyridoxine 50-100 mg daily for PMS (symptoms include acne, tender breasts, bloating, feeling tired, irritability, and mood changes.).

💬 *HRT* TOPICS TO DISCUSS

discuss with the patient about 💬 their symptoms 💬 are they postmenopausal or perimenopausal 💬 their *medical history* (see below) 💬 choice of *preparation*: tablet/patch/intravaginal 💬 *SADE* modifications 💬 *risks* (↑breast ca, thromboembolism and benefits (to control vasomotor symptoms associated with menopause and to improve quality of life; *benefits* outweigh the risks until >60yrs) 💬 continue to be *breast self-aware*; seek medical advise if you notice any lumps 💬 warn that *breakthrough bleeding* (defined as between normal menstrual periods or during pregnancy) is common in the first 3 months of initiating treatment and should be reported at next appt. - if abnormal bleeding starts within 6 months of initiating continuous prep treatment; reduce oestrogen dose - if abnormal bleeding starts beyond 6 months of initiating continuous prep treatment; refer for hysteroscopy ➼ examine: *BP, weight/height (BMI)*

*FEMALE INFERTILITY CAUSES* - inability for couple to perceive despite regular sex for more than 1 year

female - ovulatory disorders (25%) i.e. PCOS - outflow tract abnormalities (15-20%) 1) tubal factors (20-30%): pelvic adhesions, PID, ligation 2) cervical pathology (5%) 3) uterine pathology (<5%): congenital malformation, adhesions, fibroids, infection - endometriosis (15%) women could also have psychiatric issues with sex: *genitopelvic pain/penetration disorder* - persistent or recurrent difficulties during sexual intercourse with vaginal penetration difficulty, vulvovaginal or pelvic pain during intercourse, anticipatory anxiety, and pronounced tightening of the pelvic floor muscles during attempted vaginal penetration. - often presents in individuals with relationship issues (e.g., sexual problems also present in the partner), poor body image (e.g., body dysmorphic disorder), and psychiatric disorders (e.g., depression, anxiety). - treatment is with pelvic floor physical therapy male issues - varicocele (40%) - idiopathic(>20%) - obstruction(~15%) - cryptorchidism (~8%) - immunologic (~3%)

*ANTIPHOSPHOLIPID SYNDROME* - autoimmune disease affecting cell membranes leading to a hyper-coagulable state - common in young women: consider this with young women who present stroke, DVT/PE or miscarriages.

hyper-coagulable state leads to - arterial thrombosis: MI, stroke, limb ischaemia, endocarditis - venous thrombosis: DVT/PE, renal failure, livedo reticularis - pregnancy related issues: miscarriages - neurological: headaches, seizures labs: - aPTT prolongation - serum VDRL is false positive - positive anticardiolipin, antiB2 glycoprotein Ab, lupus anticoagulant management: aspirin, warfarin (if had a clot)

*HYSTERECTOMY* - a very common procedure that as a GP; you may need to explain to the patient - there are two types: *VAGINAL* (most common) and *ABDOMINAL* hysterectomy indicated for: uterine fibroids, endometriosis, adenomyosis, uterine prolapse, pelvic pain, AUB, cancer (endometrium, ovaries, fallopian tubes, cervix)

hysterectomy: a surgical procedure that involves removal of the womb primarily and possibly surrounding tissue depending on the indication e.g. fallopian tubes, ovaries, cervix. The surgery might be minimally invasive or open depending on the surgeon's choice. indications for hysterectomy - endometrial hyperplasia - symptomatic uterine fibroids - uterine prolapse - endometriosis, adenomyosis - pelvic pain - AUB - cancer (endometrium, ovaries, fallopian tubes, cervix) the risk of complication is low; they include: anaesthesia risks, bleeding, infection and injury to nearby nerves, vessels and organs; in this case; ureters, bladder or rectum affecting their function. If your ovaries are removed; then you would enter a stage of menopause because the hormone oestrogen can no longer be produced; medications would be given to help relieve the associated symptoms.

*OVARIAN CYST MANAGEMENT*

if pre-menopause with asymptomatic cyst <5cm; re-evaluate in 8-12 weeks with US. Likely to be functional cyst that in 70%, disappear within 6 weeks if postmenopausal: request CA-125. If normal; continue routine monitoring laparoscopy is recommended for cysts that are 5-10cm and symptomatic

*FEMALE ATHLETE TRIAD SYNDROME*

observed in overly excessive physically active females. It involves three components: 1) low energy availability with or without disordered eating 2) menstrual dysfunction 3) low bone density/osteoporosis (due to low oestrogen) - a DEXA scan should be ordered for those excessive athletic women with amenorrhoea >6 weeks.

*BREAST CANCER*

risk factors: increasing age (most important), family history, HRT>5 years, OCP >10 years, alcohol, high exposure to oestrogen (obesity, nulliparity, early menarche, late menopause s/s: unexplained breast lump +/- skin changes complications: mets to LN, liver, lung, bone referral within 2 weeks for: - >30yrs with an unexplained breast lump with or without pain or - >50yrs and over with any s/s unilaterally (1) discharge, (2) retraction or (3) other changes of concern management - surgery +/- radiotherapy +/- chemotherapy - hormonal therapy: tamoxifen: stops oestrogen binding to oestrogen receptor+ cancer cells - aromatase inhibitors - ovarian suppression with goserelin; a LHRHa - biologics for HER2 positive cancers

*ADENOMYOSIS* - extension of endometrial tissue into the myometrium

similar to endometriosis except - older age: typically 40-50 years - more common with multiparous women than nulliparous - dysmenorrhea, menorrhagia, and chronic pelvic pain that worsens during menstruation.

*PREMENSTRUAL SYNDROME (PMS)* - source: Toronto notes physiological and emotional disturbances that occurs 1-2 weeks prior to menses and last a few days until after the onset of menses; - affective s/s: depression, irritability, tearfulness, and mood swings - somatic s/s: breast tenderness, abdominal bloating, headache, extremity swelling *PREMENSTRUAL DYSMORPHIC DISORDER* - PMDD is PMS but more extreme; it causes extreme mood shifts that can *disrupt work and damage relationships*.

treatment for PMS - first line: exercise, CBT, vitamin B6, OCP, low dose SSRI - second line: oestradiol patches + progesterone oral/vaginal (e.g. drospirenone) or high dose SSRI - third line: GnRH analogs - fourth line: surgical treatment +/- HRT

*DERMATOLOGY STUFF - BARTHOLIN'S CYST/ABSCESS* Bartholin's glands are found on the labia majora and secrete fluid that acts as a lubricant during sex. The fluid travels down ducts, into the vagina. If the ducts become blocked, they can fill with fluid and expand to form a cyst.

usually affects sexually active women aged between 20 and 30 s/s: soft pea-sized painless lump that may grow causing pain in the vulva when walking, sitting down or having sex. management - soaking in warm water QDS + analgesia or warm compresses - if abscess: incision and insertion of a word catheter for drainage; helps cure problem permanently

*ENDOMETRIOSIS* - presence of endometrial tissue outside the uterine cavity; most commonly in the ovaries - pain resolves only with menopause - pain worsens prior and during menses differential - PID, adenomyosis,

usually young women: 25-30 years with symptoms regressing after menopause symptoms: mostly asymptomatic otherwise: - sacral backache - dysmennorhoea (painful cramps) prior to menses - menorrhagia (heavy bleeding) - deep dyspareunia (painful sex) - cyclic bladder/bowel issues e.g. diarrhoea - may complain of infertility (30-40% of those with endometriosis will be infertile) <note: there is no fever or vaginal discharge as you would see with PID> risks - reproductive age, family history, early menarche, late menopause, nulliparity diagnosis - CA125 may be raised but not used due to low specificity - definite: laparoscopy + biopsy management 1ST LINE - to control symptoms - NSAIDs - OCP: first line management - progestin* (Depo-Provera® or Visanne®) or the - *Mirena IUD* 2ND LINE: - GnRH analog e.g. leuprolide - weak androgen e.g. danazol 3RD LINE: surgery: - laparoscopy with *laser and electrocautery for ablation* - *hysterectomy + bilateral salpingo-oopherectomy*: if children not desired.

💬 *HRT* QUESTIONS FOR PATIENT

💬 ❗️history of *breast ca* 💬 ❗️history of *endometrial or ovarian ca*; (specialist advise required) 💬 ❗️*thromboembolic disease*: clots or any risk to these (better to use low oestrogen preparation) 💬 *migraines* 💬 *gallbladder disease* 💬 *last period?* perimenopausal women offered daily oestrogen and CYCLICAL progestogen (to minimise irregular bleed) while postmenopausal women given a continuous combined therapy of daily oestrogen and progestogen 💬 ❗️*breakthrough bleed* (outside periods) - if so, rule out pelvic disease 💬 *cervical smears* up to date 💬 *hysterectomy?*: if so, offer oestrogen only therapy

*MENORRHAGIA* >80ml of heavy bleeding for 7-10 days

🚩 *ENDOMETRIAL CANCER* - postmenopausal patients. if >40 years old with menorrhagia of recent onset, persistent intermenstrual bleeding or increased frequency of menstrual bleeding; refer to secondary care within 2 weeks for endometrial biopsy. 🚩 *CERVICAL CANCER* others: consider in reproductive age <40yrs 🚩 *fibroids, endometrial polyps, endometriosis*, 🚩 *pelvic inflammatory disease (STDs)*: ask about bleeding after sex (post-coital) and dyspareunia, use of IUD and multiple sexual partners contraception within first 3 months 🚩 *hormonal contraceptives*: between periods for the first 3 months if pregnant 🚩 *ectopic pregnancy/miscarriage/placenta previae* if simply unknown (40-60% cases) 🚩 *dysfunctional uterine bleeding*: 40-60% have no pathology; first line treatment is IUS (Cochrane studies suggest this is more effective than oral treatment). Alternatives include oral contraceptives, transexamic acid, NSAIDs, endometrial ablation or hysterectomy. further investigations include: urgent bloods (FBC, hCG, TFTs, pregnancy test, cervical screen, U/S (transvaginal), hysteroscopy with secondary care involvement.